April 2, 2011

Snoring: More than just Noise: Dental Solutions

Have you ever heard someone say they cannot function in the morning until they get their coffee?  Snoring may have robbed them of a good nights sleep.  Either they are snoring, their sleeping partner, or the next door neighbor.

Snoring happens when the tongue falls back in the throat, and occludes the airway during unconsciousness or sleep. This closes down the mouth and nasal openings of the airway to the lungs and forces the body to push and pull air past this obstruction.  It is when the air is forced past this obstruction that all of the various snoring sounds are emitted.   This is why the ABC’s of cardio-pulmonary resuscitation (CPR) starts with the letter “A” for airway.  If the unconscious person has difficulty breathing, then simply rotating the head back or lifting the chin will pull the tongue forward and open the airways.

This pulling of the jaw forward to open the airway is the basis behind most of the anti-snoring appliances on the market today.  The prescribed appliance is usually anchored to the upper jaw so the lower jaw can be positioned correctly.  A few of these appliances can be adjusted over time to find the optimal position and then fixed into that position for long term usage.  Over-the-counter devices that open the nasal passages such as Breath-rite nasal strips are not repositioning the lower jaw and only address some mouth breathing issues.

Effects of Snoring:


For the most part, snoring can be prevented.  Wearing an appliance does have some getting used to factors, and possibly TMJ/myofacial pain complication.

  • Overweight: Being overweight has many health issues.  Increasing the throat fat pads will make your throat more narrow and prone to snoring.  Sometimes just loosing 5 to 10 pounds will dramatically decrease snoring.
  • Alcohol:  After drinking alcohol the throat tissues become irritated, red and swollen.  Your muscles are in a more relaxed state and snoring can occur.
  • Smoking: Cigarette smoke contains many types of irritants.  These irritants make the throat red and swollen throughout the day.  Many people smoke in the bed as well.  Oddly enough, nicotine may actually decrease sleep apnea and may be a factor in why it is so hard to quit smoking.
  • If you have an obstructed nasal airway you may be forced to breath through your mouth.  This may cause snoring.
  • Sleep position: Back sleeping may allow the tongue to slip back and occlude the airway. However, snoring has been reported in every conceivable sleep position.
  • Anatomical structures: Enlarged tonsils and adenoids can block the airways and cause snoring.  Removing them can help improve the flow of air and help prevent snoring.  A few of my patient have actually had their uvula removed hoping this will help them stop snoring.  Unfortunately, in most cases this type of treatment is not totally effective and may leave the person with a more nasal sounding voice.  (Even the Muppets have uvulas). An enlarged tongue, sometimes found in edentulous patients can also promote snoring.
  • Age: As you get older, a combination of factors come into play. Less muscle tension in the nasopharynx, sleep positions, lax lower jaw positions, increased weight, loss of teeth causing the mouth to shut more, and increased prescription medications can increase snoring.
  • Obstructive Sleep Apnea: (OSA) This is a life threatening condition.  It is where you actually stop breathing when you are sleeping.  Long periods of not breathing lowers oxygen levels and increased carbon dioxide.  Both the lowering of O2 and increasing of CO2 causes the body to gasp for a breath.  This gasping creates a negative pressure inside your chest cavity putting pressure on your heart.  This causes the heart to pump harder and increases your blood pressure high enough in some instances to cause a heart attack or stroke.  This condition is diagnosed by a sleep study called a polysomnography(PSG).  Approximately 30 million Americans have sleep apnea and is characterized by snoring, hypertension, cessation of breathing during sleep, being tired during the day, and a neck size of >17″ in males and >16″ in females.
  • Upper and lower jaw mismatch: The position and size of your upper and lower jaws may have a lot to do with your propensity for snoring.


    • Lossing weight: One of the biggest reasons why a person will snore when sleeping is excessive weight in the neck.
    • Limit alcohol:  Not only will excessive alcohol increase your weight over time, but it irritates the throat tissues and make them swell, shrinking the airway and causing snoring.  Drinking alcohol should be limited and stopped within 3-4 hours before going to bed.
    • Stop smoking: (Red swollen throat, heat, nicotine)
    • Continuous Positive Airway Pressure (CPAP) uses a air pump and a mask to force air into your lungs all night long.  The masks are custom fitted to your face for maximum comfort.  It may be hard for you and your significant other to get accustomed to the noise.  This positive airway pressure opens the airways like an “air stent” so a smooth flow of air can be achieved even through a restricted passageway.  A new “Obama Care” ruling on insurance for CPAP states that the patient has to prove compliance with using the the device or it can be repossessed.  I guess too many people are diagnosed with sleep apnea and are given this expensive equipment only to let it sit at their bedside without using it.
    • Dental Appliances: There are many different types of dental appliances used to advance the lower jaw to help prevent snoring.  The trick is finding the best one for you.  Comfort is the most important factor in choosing an appliance.  Other problems may include the size of the appliance, TMJ discomfort, sore teeth and gums.  Currently they are rated as a class 2 medical device which means they require a prescription from a doctor.  (SEE the review of dental appliances below).
    • Surgical: (For extreme cases only)
    • Uvulopalatopharyngoplasty is a surgery mean to open the posterior airways by removing the uvula and part of the back wall of the pharynx.  I have several patients that have gone for this extreme surgical “cure” only to be disappointed with the overall results.
    • Radiofrequency ablation is relatively new and uses a radio frequency and heat to scar the internal tissues on the nasopharynx to make them stiffer.  The thought is that flabby tissue assists snoring and stiff tissue does not.  Early reports show improvement, but not complete elimination of the snoring sound.
    • Removal of tonsils and adenoids
    • The Pillar Procedure:  This is another surgical procedure mean to stiffen the soft palate so the tissues are less prone to vibrate during sleep.  It consists of placing up to 6+ long dacron inserts into the soft palate.  It is a relatively easy surgery that can be easily done with local anesthesia in just a few minutes.  It again lessens the snoring and may not completely eliminate it due to other complicating factors.
    • Orthognatic Surgery: This is moving either the upper or lower or both jaws to re-position the anatomical structures so that they are not restricting the airways to cause snoring.  This is the most extreme surgical procedure to totally eliminate snoring and probably the most promising.  Next to loosing excessive weight, limiting alcohol and stopping smoking, orthognatic surgery has been shown to be a good treatment for snoring.  This is done by pulling the bones of the face outward away from the nasopharynx and creating more space to breathe through.
    • Pharmaceutical: Either in the form of a nasal spray or orally, decongestants can help with snoring.  This may not be advised to take on a routine basis due to side effects of the medications including rebound rhinorrhea (runny nose).
    • Singing: This may strengthen the throat muscle enough to help prevent snoring.
    • Didgeridoo: Playing a ancient Aboriginal instrument called the didgeridoo vibrates at such a low frequency it may actually strengthen your throat muscles enough to prevent snoring. However, playing other wind instruments in either a band, orchestra, or just for fun does not decrease the chances of you having sleep apnea or snoring.

Anti-snoring devices on the market:

There are as many different types of anti-snoring devices on the internet as there are snorers in the whole world!  Some are okay and some are down right kookie.

The American Academy of Sleep Medicine has approved custom made dental appliances for:

  • Mild to Moderate obstructive sleep apnea
  • Mild to Moderate obstructive sleep apnea who prefer a dental appliance verse CPAP
  • Moderate to Severe obstructive sleep apnea who cannot tolerate or do not respond to CPAP

Dental Appliances: (custom Class 2 Medical devices by prescription only)

  • Thornton Adjustable Positioner.  This device has gone through a few generations of invention and is currently on the third version called the TAP3.  You must have teeth on the upper and lower arch for this to work or at least implants. It has an adjustable screw that can be adjusted by the dentist for optimal jaw comfort and effectiveness.  To make this device the doctor will make accurate upper and lower models of your mouth and take a bite registration.  The lab will then use and hard/soft thermoplastic material and suck in down over the models to make this device.  Its retention in the mouth depends on if you have enough teeth in both arches with enough undercuts to secure the device.  This is one of the most popular devices to substitute for CPAP when a patient cannot tolerate CPAP.  If you do not have any teeth in one or both arches then implants can be used to not only fixate your dentures but to fixate the TAP as well.  I like this appliance because it is one of the few that can be placed in the mouth one arch at a time and then you simply push your jaw forward to connect the two, positioning your lower jaw in a comfortable forward position.  One draw back for this appliance is that it traps the tongue and doesn’t allow it the freedom it needs during the night.
  • Somnodent MAS (Mandibular Advancement Splint)  This appliance fits over the upper and lower teeth just most of the other dental snoring devices and is approved by the FDA and is back by over 7 years of research.  It is one of the most comfortable mandibular advancement devices on the market today.  It is fully adjustable and allows the lower jaw a great deal of freedom.  It is effective in mild and moderate obstructive sleep apnea and snoring.  The company notes that success in all cases cannot be guaranteed.  It is a more expensive “knock-off” of the Nor-Snor 2.
  • SUAD It also is a device to move the lower jaw forward. It does provide more freedom of movement than the TAP3, but not as much as the Somnodent MAS.  It is also used in the treatment of mild and moderate sleep apnea when someone cannot tolerate CPAP.  Their website states that since the year 2000, over 8000 have been made for patients. One would have to wonder that if there are over 30 million Americans suffering from snoring/sleep apnea, why are so few being dispensed?
  • OASYS This is a most interesting device.  It comes in two pieces just like most of the other appliances, but the upper is strictly for tooth retention.  This retention is exactly the same as an Essix post-orthodontic retainer.  The lower part fits over the lower teeth to support the lower jaw advancement, but instead of attaching to the uppers it uses a “bumper” over the front teeth to keep the lower jaw in proper position.  This is supposed to use the front teeth’s proprioceptive abilities to “gently” keep the jaw in position.  In addition to the jaw repositioning, they claim that by placing “nasal buttons” under the upper lip, they can stretch out the nasal opening thus increasing the air flow through the nasal cavity by some 48%!  (Not a Class 2 medical device)
  • Silent Nite This is one of the simplest mandibular advancement appliances out there on the market.  We have used them in the past, but found they were too easy to break or chew up.  They are not as adjustable as other more sophisticated devices, but generally do well if they are take good care of.  It is basically a suck down hard/soft night guard material that fits over the upper and lower teeth with a piece of white nylon type material connecting the two together.  This connection only allows the lower jaw to rotate forward when it becomes lax, thus repositioning the jaw forward when sleeping.  (Not a Class 2 medical device)
  • Silencer Professional Again, a device to repositioning your lower jaw forward, but this time it is done with a patented version of a velcro looking material.  Simply place the upper and lower retention units in place and then put your jaw forward and bite the “velcro” together.  When cleaning the device simply pull the upper and lowers apart.  Pretty cleaver, however, gives no room for any movement throughout the entire night, and this may lead to TMJ discomfort in the morning. (Not a Class 2 medical device)
  • Tongue Retaining Device are devices that generally “suction cup” onto the tongue not letting it fall back into the back of the throat during sleep.  (Not a Class 2 medical device)
  • AveoTSD (Tongue Stabilizer Device) I ordered one of these devices for myself.  It looked like a giant pacifier.  You squeeze the bulbous part that protrudes out of your mouth and “suction cup” it to the tip of your tongue.  I found it most uncomfortable and hard to swallow, but I eventually got off to sleep.  In the middle of the night I woke to find my tongue burning.  I took off the suction cup (now half full of saliva) and noted in the mirror my tongue had a circular ecchymosis (hickey) where the device was attached.  Throughout the next day my tastes were very metallic, and my tongue burnt.  This is definitely a device I will not be prescribing for my patients.  (Not a Class 2 medical device)
  • The Moses Appliance: This is a new product on the market that is beginning to get more attention.  It is made in two parts; upper Essix type suck down clear plastic splint to stabilize the upper arch and a lower adjustable jaw positioner.  It allows the tongue freedom to move around at night and doesn’t lock together allowing you to speak and drink with it in place.  I wear it every night to treat my moderate OSA.
  • The Dorsal:  This is the same as the “SomnoDent MAS” appliance design.
  • The Nor-Snor: This is the original  “SomnoDent MAS” appliance design.

Dental Appliance Troubleshooting:

  • The retention of the device depends usually on undercuts between and around the teeth.  This allows the device to “snap” into place.  If these undercuts do not exist, then the device can be pushed out at night by the tongue.  The doctor can place white filling material in spots throughout the mouth to assist in retention.
  • After wearing the device, especially one that does not allow movement of the lower jaw, the teeth may not “match-up” immediately after removing it in the morning.  This “acquired malocclusion” can sometime persist throughout the day and cause myofacial pain syndrome.  The reason for this mis-match of your upper and lower teeth is that keep your jaw in one position all night allowed joint fluid to full all the spaces in the TMJ.  Chewing on a “rubbery” strip on some kind (plastic straw, rubber, leather) immediately after taking it out in the morning for about 10 minute (or until you feel your teeth come back together the right way) will help gently push out these fluids in the TMJ, and prevent these problems. For our patient we make a thermoplastic repositioner that the patient puts into their mouth for up to 30 minutes in the morning and this prevents any feeling of malocclusion commonly felt when wearing an obstructive sleep apnea appliance or anti-snoring appliance or hard occlusal guard at night.
  • Dry mouth: Placing a xylitol and/or fluoride containing non-alcoholic mouthwash into the device before placing it in the mouth can help.

Additional Information:

www.ApneaDocs.com – Dental Organization for Sleep Apnea

www.QuietSleep.com – a sleep-breathing disorders resource for dentists and patients

www.DentalSleepMed.org – Academy of Dental Sleep Medicine

www.ApneaNet.org – the Apnea Patients New, Education and Awareness Network


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